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Understanding how to use pricing networks This idea confounds a lot of people: They believe that pricing networks—often referred to as "insurance networks" by laypeople—and insurance firms are interchangeable terms by dental billing company . They aren't. Pricing networks and commercial insurance providers are two distinct entities. A pricing network may or may not pay claims; rather, the network may just price the claims. The payment is made by the payer or plan administrator. Some business payers join in pricing networks as opposed to handling their own contracts. They might even take part in multiple networks at once. You should be familiar with pricing networks because they function for commercial payers. Chapter 6 provides a detailed explanation of pricing networks, but the parts that follow focus on the considerations you should make while using them. acting as brokers Companies that offer network pricing are essentially the intermediaries between the payer and the provider. Pricing network contracts require a large discount on the provider's fees, much like individual insurance company payer contracts do. To be in-network with the commercial payers who take part in the pricing network, the majority of providers enter into contracts with the pricing networks that serve the patients in their local area. While some pricing networks have contracts with service providers, others simply price claims for commercial payers. In this situation, the provider is not required to accept the network's reduced rate and is free to request that the unlawful discount be eliminated, allowing for the full amount of the charges that were originally quoted. As a result, when entering into a contract with a network, the provider must exercise caution in determining whose payers are covered by the network. In the section that follows, "Avoiding network pitfalls: The silent PPO," you can read more about that subject. Providers should identify the plans and networks in which they participate, and patients (or the payers for the patients) should identify the network(s) to which they are a member. You want to keep in touch with your provider so that you are aware whenever a contract with a new payer has been entered into so that you can stay on top of the network specifics as the coder (and person who gets to negotiate all of this contract crazy). You need to examine the patient's insurance card in order to know which pricing contract should be used for any given claim. Network pitfalls to avoid: The PPO silence Providers must insist when entering into a contract with a network that all plans that access the network be disclosed upfront and that they be informed when new payers are included in the network. Some network agreements have the drawback of allowing payers to occasionally enter the network through a back door. In other words, these payers are permitted access to the network contract even though they are not originally recognized as network members. A quiet PPO is what this is, and it's bad for your provider. This is how a silent PPO function: Sometimes a PPO network contract contains language that essentially permits the network to enter into a contract with any "individual, organization, firm, or governmental entity" on a case-by-case basis, meaning that any participant who is willing to pay the commission can access the PPO contract — and its negotiated discount pricing — without the knowledge of the provider. See the issue? Without technically having a contract with the healthcare provider, a payer can use a silent PPO to apply a discount rate for services. Providers who sign a contract with the network and its users—a deal that, at the time of signing, did not include the silent PPO—are treated unfairly in this case. As a result, the silent PPO defrauds the provider of a just payment when it pays the lower fee. Here are some methods for spotting a silent PPO and avoiding becoming a victim: Pay close attention to the description of the advantages (EOB). If you look at the EOB, you can see when a payer accesses a silent PPO (explained in Chapter 13). A silent PPO alarm should ring to you if it shows a PPO discount for a patient who is genuinely out of network. Steer clear of networks that permit reimbursements that are significantly higher than those permitted by other business insurance providers. Payers are for-profit companies. If a player is willing to pay more than the market rate, you can expect that it will receive payment from the entity that is actually in charge of making the payment on the other side. For instance, if a network is ready to pay $750 for a service that costs $1,500 but is typically paid $500, the additional $250 must come from somewhere. The likelihood is that it comes from a non-network subscriber who is prepared to pay $1,000 to the network rather than $1,500 to the service provider by medical coding services . ✓ As part of the routine pre-meeting work for your provider, confirm network advantages. You should examine each patient's card's network affiliations, or the front desk employees should do so.

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